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Evaluating Lean in healthcare
Nicola Burgess
Warwick Business School, University of Warwick, Coventry, UK, and
Zoe Radnor
Cardiff Business School, Cardiff University, Cardiff, UK, and
School of Business and Economics, Loughborough University,
Loughborough, UK
Abstract
Purpose – The purpose of this paper is to present findings relating to how Lean is implemented in
English hospitals.
Design/methodology/approach – Lean implementation snapshots in English hospitals were
conducted by content analysing all annual reports and web sites over two time periods, giving a
thorough analysis of Lean’s status in English healthcare.
Findings – The article identifies divergent approaches to Lean implementation in English hospitals.
These approaches are classified into a typology to facilitate an evaluation of how Lean is implemented.
The findings suggest that implementation tends to be isolated rather than system-wide. A second
dataset conveys Lean implementation trajectory across the time period. These data signal Lean’s
increasing use by English hospitals and shows progression towards an increasingly systemic
approach.
Practical implications – Data were collected using content analysis methods, which relies on how
“Lean” methods were articulated within the annual report and/or on the organisation’s web site, which
indicates approaches taken by hospital staff implementing Lean.
Originality/value – This research is the first to examine more closely “how” Lean is implemented in
English hospitals. The emergent typology could prove relevant to other public sector organizations
and service organisations more generally. The research also presents a first step to understanding
Lean thinking in the English NHS. This article empirically analyses Lean implementation in English
hospitals. It identifies divergent approaches that allow inferences about how far Lean is implemented
in an organisation. Data represent a baseline for further analysis so that Lean implementation can be
tracked.
Keywords Lean, Health care, Implementation, NHS England, National Health Service, United Kingdom
Paper type Research paper
Introduction
The English National Health Service (NHS) is a public sector organisation with a
longstanding objective to deliver high-quality healthcare free at the point of use.
Persistent NHS reform and calls for improved efficiency are considered prominent
drivers of process improvement methods such as Lean (Radnor et al., 2012; Radnor,
2010). During the last Labour government, Cole and Radnor (2010) report a gradual
shift towards increased governance and accountability, creating widespread pressure
to meet stringent performance targets. Performance in this regard is closely audited by
inspectorate bodies such as the Care Quality Commission (CQC) and the foundation
trust (FT) independent regulator, Monitor. Since 2004, the best performing NHS trusts
could apply to Monitor to become a new organisation known as a foundation trust,
which confers greater financial and operational freedom on trust managers. Ascension
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0952-6862.htm
IJHCQA
26,3
220
Received 11 November 2010
Revised 6 May 2011
Accepted 29 May 2011
International Journal of Health Care
Quality Assurance
Vol. 26 No. 3, 2013
pp. 220-235
q Emerald Group Publishing Limited
0952-6862
DOI 10.1108/09526861311311418
to FT, however, involves extensive and rigorous assessment (NHS Choices, 2009),
representing a government drive towards devolved decision making (Monitor, 2009).
Calls for efficiency and performance targets led to process improvement methodologies
such as Lean, which is based on continuous improvement focusing on value, flow and
waste reduction. A recent literature review of business process improvement
methodologies found that 51 per cent of publications focused on Lean (35 per cent in
the health services) (Radnor, 2010). Further evidence of Lean implementation in
healthcare is proffered by reports in the main and grey literature (Brandao de Souza,
2009; Young and McCLean, 2008). Despite indications that Lean is prevalent in
healthcare, many authors regard Lean implementation to be pragmatic, patchy and
fragmented (Proudlove et al., 2008; Young and McCLean, 2008). To be effective at
delivering sustained and continuous service improvement, Lean implementation
should be aligned to organisational strategy, where Lean becomes part of the
organisational culture (Davies and Walley, 2000; Corbett, 2007; Ben-Tovim et al., 2007;
Hines et al., 2004; Hines et al., 2008). Here, we seek to evaluate empirically how Lean is
implemented in healthcare, specifically English hospitals, so that its impact can be
understood. We present three key findings: Lean implementation continues to be
popular in English hospital trusts; managers are implementing Lean in different ways
ranging from tentative exploration to systemic approaches; and hospital managers
have enhanced and elevated their approach to Lean implementation in line with an
organisation-wide programmes aligned to organisational strategy.
Background
Originating from the Toyota Motor Corporation in Japan, Lean (also referred to as the
Toyota Production System) was initially conceived as a radical alternative to
traditional mass production. This alternative manufacturing-method was conceived
when scarce resources and a financial crisis in Japan rendered mass production
practices (where products could be made cheaply in large quantities and stockpiled for
later sale) as infeasible (Cusumano, 1988; Holweg, 2006; Oliver, 2008; Seddon et al.,
2009). Womack et al. (1990) and Womack and Jones (1996) are widely credited as
popularising Lean in the West, coining the term “Lean Thinking” and articulating
Lean’s five core principles that guide its implementation. Lean is based on an
underlying assumption that organisations are made up of processes – linked activities
that have a specific order and space, with a beginning, an end and clearly defined
inputs and outputs (Davenport, 1993). Such processes can traverse and interlock with
other sub-processes or form the beginning/end of another procedure. Thus a process
perspective means moving away from traditional functions focused around
organisational activities towards creating value from the customer’s perspective
(Davenport, 1993). McNulty and Ferlie (2002, p. 20) elaborate: “a process perspective is
concerned with value creation rather than merely control of the value creation process”.
Lean is about making “value” flow at every step where value is what a customer would
pay for and waste is what a customer would not pay for. Lean, therefore, is primarily
about improving quality so that non-value adding activity (i.e. waste), which often
adds delay, requires extra resource (and ultimately attracts extra costs), should be
eliminated. Lean principles are promoted as a universal guide to its implementation
(Womack and Jones, 1996; Porter and Barker, 2005):
Evaluating Lean
in healthcare
221
(1) Specify value from the customer’s perspective. Probably Lean’s most important
element is specifying and identifying value. As Womack and Jones (1996, p. 141)
state: “failure to specify value correctly before applying Lean techniques can easily
result in providing the wrong product or service in a highly efficient way.” In
healthcare, however, value is conceived as multifaceted and indeterminate.
Interpretations and perspectives vary widely. Young and McCLean (2008) define
value from a patient pathway perspective – the route patients take from entry into
hospital until s/he leaves; i.e. designing pathways around creating value to patients
at each step rather than considering patient-centred activities such as radiology,
pathology and ward care for example, as isolated processes or “functional silos”.
(2) Identify the value streamfor each product/service provided and challenge all
wasted steps by mapping all processes involved in creating a product/service.
One might map the stroke patient pathway to identify value and non-value
adding activity. Process start and end points under consideration need to be
agreed in advance to keep the improvement focussed and manageable; for
example, the mapped process might start from stroke onset, hospital journey
(ambulance, walk-in patient or GP referral) and the process end-point in an
acute care setting context might be patient discharge. In practice, the mapping
activity is conducted by people who “touch” the patient pathway at different
points (call handler, paramedic, nurse, matron, specialist doctor, departmental
manager, etc.), later coming together to map the process. The outcome should be
an enhanced understanding of process aspects to challenge the steps not adding
value to the customer/patient.
(3) Make the product/service flow continuously and standardise processes around best
practice, which means redesigning the process and eliminating non-value adding
activity such as waiting for a bed, a specialist doctor or medication, for example.
(4) Introduce “pull” between all steps where continuous flow is impossible.
Recognising that it might not be possible to eliminate all non-value adding
steps immediately, this principle aims to eliminate waste as far as possible by
“pulling” the customer/patient to the next process step. For example, theatre
staff might telephone ward nurses to ask if there is a bed available for a patient
while s/he is in the recovery bay following surgery; this action presents an
attempt to push patients from one location to another. If there are no beds
available in the ward or no one available to answer the phone then the recovery
ward will soon become blocked consequently inhibiting theatre staff.
Conversely, a “pull” process would involve ward staff releasing beds to
patients in theatres based on their patient-demand knowledge.
(5) Manage towards perfection. Systematically eliminating waste to achieve an
ideal process where value is created at every step should become part of
organisation culture, where Lean becomes “the way we do things around here”,
so that non-value adding activity is continuously removed and the steps, time
and information needed to serve the customer/patient continually falls.
Toussaint and Gerard (2010) simplify these principles for healthcare as: focus on the
patient and design care around them; identify value for the patient and get rid of
everything else (waste); minimise time to treatment and through its course.
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Lean thinking and healthcare
Transferring Lean to healthcare is relatively new. Brandao de Souza (2009) identifies
the first reference to Lean in UK healthcare by the NHS Modernisation Agency (2001).
Since then over 90 publications from ten countries refer to Lean in healthcare (Brandao
de Souza, 2009). Balle and Regnier (2007, p. 33) account for Lean’s popularity in
healthcare owing to a “double focus of Lean on customer satisfaction and employee
involvement [that] suits the culture of most care centres”. Similarly, Gary Kaplan,
Virginia Mason Medical Centre (VMMC) Chief Executive Officer (CEO), Seattle, cites
similarities between Lean and healthcare philosophies, primarily “putting the customer
first, a focus on quality and safety and a commitment to employees’ (Bohmer and
Ferlins, 2006, p. 4). However, according to Spear (2005, p. 91): “in healthcare, no
organisation has fully institutionalised to Toyota’s level, the ability to continuously
and systematically eliminate waste.” His contention is largely supported in the
literature, which identifies Lean implementation in healthcare as patchy and
fragmented (Young and McCLean, 2008; Proudlove et al., 2008; Balle and Regnier,
2007). Authors argue that a disjointed approach to Lean implementation delivers
pockets of best practice (Holweg and Pil, 2001; Radnor and Walley, 2008), which
potentially have a negative impact on the wider healthcare system (Towill and
Christopher, 2005; Waldman and Schargel, 2006). Some hospitals have become seminal
examples of Lean implementation, notably: VMMC in Seattle, USA; Flinders in
Australia and the Royal Bolton NHS Foundation Trust (RBH), UK (Bohmer and
Ferlins, 2006; Ben-Tovim et al., 2007; and Fillingham, 2008). Gubb (2009) notes the
Flinders Medical Centre achievements, which after two-and-a-half years was doing
15-20 per cent more work, with fewer safety incidents, on the same budget, using the
same infrastructure, staff and technology. Gubb (2009) also cites a reduced average
turnaround time in pathology from over 24 hours to two to three hours using less space
and fewer resources by staff at RBH. The RBH staff commitment to Lean, part of the
hospital’s long term strategy, is evidenced by its investment in Lean training across the
hospital aligned to career progression. David Fillingham (2008, p. 129), formerly Royal
Bolton’s CEO, explains:
[. . .] all 3,500 staff are to be trained to green level. Those wanting to progress to a first-line
supervisory role will be expected to achieve a bronze accreditation, while those in senior
management positions will be expected to achieve silver [. . .] “those who aspire to director
level or become part of the central Bolton Improving Care System (BICS) team [internal
improvement team] will be expected to train to the Gold standard.” The platinum level is
described as “a lofty aspiration” close to “sensei”.
Aim and method
Our research: explores how Lean is implemented in English hospitals; and provides
baseline data against which Lean implementation trends in healthcare can be tracked.
We contend that discernible approaches to Lean implementation exist in healthcare
and these approaches may progress over time towards an emerging culture where
Lean becomes “the way we do things around here”. We present data collected at two
points – 2007/2008 (T1) and 2009/2010 (T2). Our research design was guided by
Pettigrew and Whipp’s (1991) strategic change context-content-process model. The
“context” dimension refers to the “why” of change; “content” refers to “what”; and
“process” to “how”. The rationale for employing this model as a data-collection
Evaluating Lean
in healthcare
223
framework is that Lean implementation requires change at both strategic and
operational levels (Hines et al., 2004, 2008). Our research adopts Pettigrew’s (1990,
p. 268) view: “theoretically sound and practically useful research on change should
explore change contexts, content and process together with their interconnections
through time. The aim is to catch reality “in flight”. The model is widely used to
analyse NHS change programmes (Pettigrew et al., 1992; Iles and Sutherland, 2001;
Stetler et al., 2007). The model’s basis is the contention that these three dimensions are
interrelated and any study in the NHS must consider all three dimensions. Figure 1
illustrates how the model guides data collection.
Data collection
Using content analysis (Weber, 1990), we examined all T1 and T2 annual reports from
English acute (excluding specialist) hospitals using a combined narrative analysis and
the key word in context (KWIC) approach (Grbich, 2007). Annual reports were chosen
as the main data source because trust managers are required to publish reports
covering the previous 12 months for Parliamentary purposes (Schedule 7, paragraph
25(4), National Health Service Act 2006). These reports are available to the public via
hospital web sites and generally adopt the standard structure (see the following list).
Guidance for annual report structure and content
. directors’ report including a management commentary;
. a remuneration report;
. disclosures set out in the NHS Foundation Trust Code of Governance; and
. other disclosures in the public interest.
The commentary (inthe previous list) is usually written by the trust’s chairman and
chief executive and contains a narrative relating to highs, lows, strengths, weaknesses
and challenges (often financial or performance-oriented) faced by trust managers over
Figure 1.
Pettigrew and Whipp’s
(1991) Context-Content-
Process framework
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the past year and provides an insight into the Lean implementation context. For
example:
. indicating a successful/disappointing/difficult year;
. attitude/drivers for service improvement;, e.g. a “turnaround trust” or one
claiming to be at the innovation and service improvement forefront;
. financial circumstances: whether trust managers faced a historical debt or
healthy surplus;
. key achievements and awards.
The content analysis method facilitated deriving key themes that serve as indicators
relating to the content and process of Lean implementation in the organisation. Based
on 20 annual reports, we found the following key words commonly associated with
Lean implementation:
. “Lean” – as an application/awareness of Lean methods;
. “productive” – implementing the national Productive Ward programme
commonly associated with Lean. Productive Ward (PW) is a national
programme based primarily on the “5S” tool for improving workplace
organisation and discipline (www.institute.nhs.uk);
. “releas” – base form of the word “releasing” from the “releasing time to care”
initiative used synonymously with PW;
. “waste” – reference to removing waste from processes;
. “improvement” – highlighting activities related to service improvement that
may be connected to Lean;
. ‘rapid” and “kaizen” – rapid improvement events (also referred to as kaizen
events) as Lean implementation elements often used as a vehicle for
improvement projects and value stream mapping activities;
. ‘project” – identifying projects associated with Lean methods.
Our method identified trusts articulating Lean methods in their annual reports. The
search words were often embedded within service improvement/transformation
programmes, pathway redesign projects or small discrete projects that championed
Lean methods. Tables I and II present specimen data from one trust’s annual report.
Tables I and II clarify how data were collected, how categories are arrived at and the
rationale for the awarded category. Table I focuses on contextual data forming the
basis of more detailed research that considers the context’s influence on Lean. Table II
presents data collected to determine the approach to Lean implementation by the trust.
Limitations
We acknowledged that annual reports may be incomplete, biased and distorted, and it
may be that hospital managers are using but not mentioning Lean methods in their
report. To help counterbalance this issue, we extended our method to corresponding
trust web sites, which uncovered instances where trust staff cite Lean activities, for
example, in minutes, staff magazines or documents outlining a Lean consulting tender
or reporting an early, experimental project based on Lean methodology.
Evaluating Lean
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225
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IJHCQA
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n
g
fo
u
n
d
at
io
n
s
es
ta
b
li
sh
ed
in
ea
rl
ie
r
y
ea
rs
of
b
ot
h
a
so
u
n
d
fi
n
an
ci
al
fo
ot
in
g
an
d
h
ig
h
q
u
al
it
y
se
rv
ic
es
,
an
d
to
g
iv
e
ar
ea
l
em
p
h
as
is
to
si
m
u
lt
an
eo
u
sl
y
im
p
ro
v
in
g
q
u
al
it
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w
h
il
e
d
ri
v
in
g
v
al
u
e
fo
r
m
on
ey
”
S
u
cc
es
sf
u
l
A
n
ot
h
er
su
cc
es
sf
u
l
y
ea
r
d
en
ot
es
a
st
ab
le
,
st
ro
n
g
p
er
fo
rm
an
ce
* T
h
is
is
n
ot
a
p
ic
tu
re
th
at
is
p
or
tr
ay
ed
b
y
m
os
t
E
n
g
li
sh
T
ru
st
s!
O
th
er
ca
te
g
or
ie
s
in
cl
u
d
e:
fi
n
an
ci
al
d
if
fi
cu
lt
y
;
cr
is
is
;
re
co
v
er
y
(fi
n
an
ci
al
tu
rn
ar
ou
n
d
)
am
on
g
ot
h
er
s
Table I.
Evaluating Lean
in healthcare
227
C
on
st
ru
ct
D
at
a
ex
tr
ac
te
d
C
at
eg
or
ic
al
in
te
rp
re
ta
ti
on
R
at
io
n
al
e
P
ro
ce
ss
E
le
m
en
ts
of
L
ea
n
an
d
ar
ea
s
id
en
ti
fi
ed
as
u
n
d
er
tr
an
sf
or
m
at
io
n
.
T
1:
L
ea
n
as
se
ss
m
en
ts
h
av
e
b
ee
n
u
n
d
er
ta
k
en
in
a
n
u
m
b
er
of
ar
ea
s
b
ot
h
w
it
h
in
p
at
h
ol
og
y
an
d
in
to
th
e
w
id
er
h
os
p
it
al
co
m
m
u
n
it
y
(t
h
ea
tr
es
,
su
rg
er
y
an
d
p
at
ie
n
t
ad
m
in
is
tr
at
io
n
).
P
at
h
li
n
k
s
h
av
e
al
re
ad
y
b
en
efi
te
d
fr
om
a
n
u
m
b
er
of
su
cc
es
sf
u
l
p
ro
je
ct
s
in
h
is
to
lo
g
y
,
b
lo
od
sc
ie
n
ce
s,
an
d
m
ic
ro
b
io
lo
g
y
an
d
th
es
e
sa
m
e
p
ri
n
ci
p
le
s
w
il
l
n
ow
b
e
ap
p
li
ed
el
se
w
h
er
e
in
th
e
tr
u
st
u
si
n
g
th
e
n
ew
ly
cr
ea
te
d
“L
ea
n
A
ca
d
em
y
”
(p
.
33
)
T
1:
P
ro
g
ra
m
m
e
P
at
h
L
in
k
s
is
th
e
n
am
e
g
iv
en
to
a
p
ro
g
ra
m
m
e
th
at
cl
ea
rl
y
u
se
s
L
ea
n
m
et
h
od
s.
S
ev
er
al
p
ro
je
ct
s
ar
e
id
en
ti
fi
ed
th
ro
u
g
h
ou
t
th
e
re
p
or
t
al
on
g
si
d
e
a
fo
rm
al
ac
ad
em
y
fo
r
L
ea
n
tr
ai
n
in
g
T
2.
P
at
h
L
in
k
s
h
as
u
n
d
er
ta
k
en
a
m
aj
or
ov
er
h
au
l
of
it
s
q
u
al
it
y
an
d
g
ov
er
n
an
ce
ar
ra
n
g
em
en
ts
fo
ll
ow
in
g
th
e
ap
p
oi
n
tm
en
t
of
a
L
ea
n
S
p
ec
ia
li
st
.
T
ar
g
et
in
g
L
ea
n
im
p
le
m
en
ta
ti
on
ac
ro
ss
th
e
w
h
ol
e
of
th
e
or
g
an
is
at
io
n
,
th
e
d
el
iv
er
y
of
en
h
an
ce
d
le
v
el
s
of
se
rv
ic
e
q
u
al
it
y
an
d
p
er
fo
rm
an
ce
is
th
e
ov
er
ri
d
in
g
fo
cu
s
(p
.
73
)
T
2:
S
y
st
em
ic
In
T
2,
L
ea
n
an
d
th
e
P
at
h
L
in
k
s
p
ro
g
ra
m
m
e
co
n
ti
n
u
es
to
th
ri
v
e.
T
h
e
tr
u
st
is
ca
te
g
or
is
ed
as
“s
y
st
em
ic
”
as
th
er
e
is
cl
ea
r
ev
id
en
ce
th
at
th
e
st
ra
te
g
y
is
to
im
p
le
m
en
t
L
ea
n
in
th
e
w
h
ol
e
or
g
an
is
at
io
n
.
C
om
m
it
m
en
t
to
th
is
en
d
ea
v
ou
r
is
sh
ow
n
b
y
ap
p
oi
n
ti
n
g
a
L
ea
n
sp
ec
ia
li
st
C
on
te
n
t
A
re
as
id
en
ti
fi
ed
u
n
d
er
tr
an
sf
or
m
at
io
n
an
d
im
p
ac
t
T
2:
T
h
e
ce
n
tr
al
is
ed
H
is
to
p
at
h
ol
og
y
se
rv
ic
e
in
L
in
co
ln
h
as
ra
d
ic
al
ly
tr
an
sf
or
m
ed
it
s
op
er
at
io
n
s
th
ro
u
g
h
th
e
im
p
le
m
en
ta
ti
on
of
L
E
A
N
th
in
k
in
g
an
d
w
or
k
in
g
p
ra
ct
ic
es
.
T
h
is
h
as
le
ad
to
g
re
at
ly
im
p
ro
v
ed
p
ro
d
u
ct
iv
it
y
le
v
el
s
an
d
q
u
al
it
y
of
se
rv
ic
e
as
ev
id
en
ce
d
b
y
:
D
at
a
co
ll
ec
te
d
su
p
p
or
ts
th
e
ca
te
g
or
ic
al
in
te
rp
re
ta
ti
on
of
th
e
L
ea
n
ap
p
ro
ac
h
45
p
er
ce
n
t
R
ed
u
ct
io
n
in
T
u
rn
ar
ou
n
d
T
im
e
60
p
er
ce
n
t
In
cr
ea
se
in
P
ro
d
u
ct
iv
it
y
53
p
er
ce
n
t
In
cr
ea
se
in
E
ffi
ci
en
cy
98
p
er
ce
n
t
R
ed
u
ct
io
n
in
E
rr
or
s
S
im
il
ar
im
p
ro
v
em
en
ts
h
av
e
b
ee
n
m
ad
e
in
C
y
to
lo
g
y
w
h
er
eb
y
th
e
se
rv
ic
e
fa
r
ex
ce
ed
s
th
e
re
q
u
ir
em
en
t
to
m
ee
t
th
e
n
at
io
n
al
st
an
d
ar
d
of
a
m
ax
im
u
m
tw
o
w
ee
k
T
aT
fo
r
ce
rv
ic
al
ca
n
ce
r
sc
re
en
in
g
.
In
L
in
co
ln
sh
ir
e,
al
l
su
ch
te
st
s
ar
e
re
p
or
te
d
in
le
ss
th
an
on
e
w
ee
k
Table II.
Data collected under the
strategic change
“content” dimension for
Northern Lincolnshire
and Goole Hospitals NHS
Foundation Trust
IJHCQA
26,3
228
Validity and reliability
It is up to the investigators using content analysis to judge what method is appropriate.
However, to make valid inferences, classification procedures must be reliable
(consistent) (Weber, 1990) and thereby replicable. Transparency, the explicit process
used to collect data and key words for identifying Lean implementation and explicit
rationale for coding data are critical (Grbich, 2007) (see Tables I and II). We repeated
our data collection consistently, 300 hundred times at two points in time (152
individual hospital trust reports in 2008 and 142 in 2010 – reduced owing to hospital
mergers). This content analysis approach is intended to be a Lean implementation
“overview” or “snapshot” basedon how Lean methods are articulated in the annual
report. In most cases, only small chunks of text in the annual reports referenced service
improvement activity and this text may or may not articulate or infer that Lean was
used. Thus, the extracts we analysed were treated as straightforward
Lean-implementation indicators and have not been subject to inter-rater reliability
tests. This may be perceived as a limitation; however, we feel that this weakness is
counter-balanced by the study’s high transparency levels and process repetition.
Findings
Our findings represent a snapshot of Lean implementation in English hospitals at two
points in time. During the operating year 2007/2008, 80 hospital trusts (53 per cent) in
our study cite Lean implementation in their annual reports and/or their corresponding
web sites. During the operating year 2009/2010, this figure rises to 111 trusts or 78 per
cent of the study population. Claims in the reports regarding Lean application and
implementation varied considerably – from trusts citing a few projects to those
announcing improvement programmes based on Lean principles. The Lean
implementation spectrum emerging from the dataset is presented as a typology in
the following list.
Approaches to Lean implementation – a typology
. Tentative – Trust staff are contemplating Lean, tendering for external
management consultancy to help with implementation or piloting a small
isolated project.
. Productive Ward Only (PW) – Trust staff are implementing Productive Ward
and or Productive Theatre but no other evidence of Lean implementation is
identified.
. Few projects – Trust staff are using Lean principles and methods to underpin
projects relating to certain functions or pathways within the organisation.
. Programme – Trust managers refer to Lean principles underpinning work
programmes expected to last between one and five years.
. Systemic – Trust report refers to embedding Lean principles in the trust as a
whole so that it becomes “the way we do things around here”. A systemic
implementation also emphasises Lean training for all staff.
Figure 2 illustrates the distribution of Lean implementation approaches in English
hospital trusts during T1 and T2. The graph suggests that while a “few projects”
approach to Lean implementation is most prevalent in both T1 and T2, there has been
Evaluating Lean
in healthcare
229
a significant increase in the annual reports articulating a systemic approach to Lean
during T2.
The prevalence of a “few projects” approach was largely anticipated and supports
the literature, which claims that many hospital trusts are doing a few small projects
based on Lean methods but that this approach to implementation does not form an
integrated approach to service improvement (Radnor, 2010; Young and McCLean,
2008; Spear, 2005). What is particularly interesting, however, is the rise in hospital
trust managers articulating a more advanced implementation of Lean in their annual
reports (37 in T2 compared to 27 in T1 claiming to be taking a programme or systemic
approach). This finding leads us to consider the trajectory between approaches.
Figure 3 illustrates hospital trust movements from one implementation approach to
another. The central diagonal denotes trusts categorised as taking the same approach
in T2 as T1. To the right of the diagonal are trusts that increased their Lean
implementation and to the left are the hospitals that appear to have scaled down their
Lean implementation or stopped altogether.
Figure 3 shows 51 trusts (36 per cent) appearing to have maintained activity.
However, there is an early indication towards a more systemic and strategic approach
Figure 2.
Lean implementation in
English hospital trusts
Figure 3.
Comparing approaches to
lean implementation
during T1 and T2
IJHCQA
26,3
230
to Lean implementation in English hospital trusts. Seventy trusts (49 per cent) moved
to the right of the central diagonal, denoting a progression from localised approaches to
Lean implementation to one that is more system focused. Of 28 trusts identified as
taking a “few projects” approach in T1, 14 continued this approach in T2, five trusts
formalised the approach as a “programme”, and three appear to have aligned Lean to
organisational strategy, thereby warranting a systemic classification. Of those trusts
identified as taking a programme approach in T1, five progressed towards a systemic
organisation-wide approach in T2; five appear to have scaled down to a few projects or
PW and three appear to have stopped implementing Lean. In total 13 trusts appear to
have stalled Lean implementation during T2; i.e. Lean was not mentioned in the annual
report despite being reported in T1.
Discussion
Shah and Ward (2007, p. 791) state that Lean is “an integrated socio-technical system”
and should be considered to be a set of tools, techniques and practices (which can often
be easily emulated) combined with a cultural or social system (it takes time to change
organisational principles and routines). Figure 2 depicts only five hospitals taking a
systemic approach to Lean implementation in T1 rising to 15 in T2. “Productive Ward”
or “few projects” trusts could be viewed as taking short-term and localised approaches
to improvement, probably driven by national performance and efficiency targets;
i.e. focusing on the imminent pressures facing the organisation rather than a strategy
for long term improvement (Radnor and Walley, 2008). This approach reflects the
perception of Lean implementation in healthcare as fragmented, focussing on Lean’s
visible elements – tools and technology – but fails to address its less-visible strategic
elements and enabling factors relating to leadership and organisational readiness
(Radnor, 2010; Hines et al., 2008). One consequence is that initiatives such as the PW
are seen as Lean and so little effort is placed into sustainable activities such as
developing a structured, problem-solving culture (Radnor and Walley, 2008; Radnor
et al., 2012). Many authors express caution about a tools-based approach. Spear (2004)
suggests that where staff merely imitate the tools and not Lean principles then the
result is a rigid inflexible system. Indeed, David Fillingham, RBH’s former Chief
Executive, warns:
The risk in creatively adapting Lean initiatives to suit your own organisation is that their
essence can easily be lost. It can degenerate into just another quality drive, or worse still [. . .]
talking shops in which nothing gets done. The trick is to recognise the core elements of a Lean
approach and embody them in all you do (Health Service Journal, 2008).
Lean is often described as a journey containing landmarks in its implementation stages
(Bicheno, 2004; Hines et al., 2008). Some researchers suggest that developing and
implementing the tools facilitate a gradual cultural and behavioural change (Radnor
and Bucci, 2007). It could be argued that for some hospital trusts, PW and a “few
projects” approach represent the start or part of the Lean “journey”, suggesting that the
approaches to Lean implementation (see previous list) may potentially depict this
journey as organisational staff move at varying paces through each stage – from
isolated applications to daily problem-solving and improvement. Figure 3 offers some
support for this contention, where trajectory is portrayed by data analysis, which
might suggest that each category represents a journey landmark. For example, the
Evaluating Lean
in healthcare
231
journey may consist of tentatively exploring Lean and its methods, followed by
experimentation with Lean tools and small projects before trust managers commit to a
service improvement programme based on Lean. The destination being where Lean
becomes aligned with organisational strategy and thus becomes part of daily working
life (Corbett, 2007).
The data however,do not suggest a linear transition from a tentative exploration
through each implementation stage. Thus, more detailed exploration is needed to fully
understand Lean implementation’s context, content and process in hospital trusts; in
line with how Pettigrew and Whipp (1991) intended their strategic change model to be
used. Pettigrew et al. (1992, p. 9) claim, “the analytical challenge is to connect the
content, context and process of change over time to explain the differential
achievement of change objectives”. Therefore, further research will gather and
combine these elements through ethnographic and case study analysis to overcome
content analysis limitations and to generate a more detailed understanding and
evaluation of Lean implementation in English hospitals. To illustrate the need to
explore context in greater detail, we examine one case. Figure 3 shows one trust
categorised as taking a systemic approach in T1, falling to “No Lean” (no evidence of
Lean implementation) in T2. Referring to the T1 and T2 data collected for this trust,
there is a clear commitment to implementing Lean based on their dedication to staff
training around Lean principles and descriptions of numerous projects based on Lean
methods. The trust’s CEO advocates Lean principles to achieve “organisational
transformation” within a supportive context:
We will foster a supportive culture in which we learn from mistakes, share best practice and
encourage staff to maximise their potential (Brighton and Sussex University Hospitals NHS
Trust, 2008, AR07/08:2).
In T2, trust managers report improved performance:
[. . .] a significant transitional year for the trust finances. With the support of the whole
organisation, and the local healthcare commissioners, the trust has delivered a surplus of £4.6
million.
Clearly, annual reports as analytical units, limit the degree to which any explanation
can be inferred, and thus without more detailed analysis one can only guess the
reasoning behind Lean’s disappearance in the trust. One explanation might be that
Lean was used towards a specific organisational goal and once achieved it was
dropped or no longer deemed noteworthy. A case study approach will facilitate a more
rigorous exploration of Lean implementation context, content and process to
understand its impact and why Lean might have stalled. Overall, 22 trusts appear to
have downgraded Lean implementation with 13 apparently stalling. Burgess and
Radnor (2010) report that Lean can stall, owing to manager mobility, quantifying the
benefits and value problems, and omnipresent financial pressures. In Brighton and
Sussex University Hospitals NHS Trust, Lean’s disappearance cannot be explained by
unstable management teams as the data reveal no issues. There is an indication,
however, that the Lean implementation-driver was related to finance, which leads us to
infer that either Lean was considered a tool rather than a strategy, or it could be that
Lean methods alongside other methods have become orthodox and thus no longer
receives attention in the trust’s annual report.
IJHCQA
26,3
232
Conclusion
We present a snapshot using content analysis methods – an approach that: facilitates
synthesising large datasets across a reasonably large study population; and enables
change over time to be compared. Further analysis is needed to explore context
influence on Lean approaches and the sustainability or progression of that approach.
This will be carried out through case studies. We present and discuss three key
findings. First, Lean implementation continues to be popular in English hospital trusts;
furthermore, its implementation has become progressively widespread. Second,
hospital trust managers are implementing Lean in different ways ranging from a
tentative exploration in the form of learning from others (hospitals and organisations
in other sectors), through to a systemic approach aligned to strategy. Third, English
hospital managers increasingly enhance and elevate their Lean implementation
approaches in line with organisation-wide programmes and to the organisation’s
strategy. We develop a greater understanding of Lean implementation in hospitals,
which contributes to understanding how implementing an approach or practice into a
context for which it was not developed (i.e. from manufacturing). Our typology and
baseline data allowed us to track implementation movement and to investigate the
movement up and down the types. Further research using more detailed and in-depth
enquiry-methods, such as case studies to build theory (Eisenhardt, 1989), is necessary
to validate our findings. Sequential data collection, to generate time-series information,
will enable researchers to explore trends during Lean’s transition that starts with
tentative exploration, a tool or a few projects that develops into a programme and
eventually into a systemic approach.
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About the authors
Nicola Burgess is a Research Fellow at the International Centre for Governance and Public
Management at Warwick Business School, University of Warwick. Nicola Burgess is the
corresponding author and can be contacted at: Nicola.Burgess@wbs.ac.uk
Zoe Radnor is a Professor of Operations Management at Cardiff Business School, Cardiff
University.
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